Evidence-Based Medicine: Are Inductions Safe?

A couple weeks back, I researched the necessity of labor induction. I learned that, according to the Listening to Mothers Survey from 2005, about 40% of all labors are medically induced. I also learned that, according to birth experts Ina May Gaskin and Marsden Wagner, induction is only medically indicated in about 10% of births. This means that about three-quarters of all women who are induced are doing so without medical indication. If induction is perfectly safe, there would be no concern — so what does the research say?

The stats…

80% of medical inductions were done using a drug called Pitocin, a synthetic oxytocin, which causes the uterus to contract. Other methods of induction include prostaglandin medications applied to ripen the cervix, stripping/sweeping the membranes, and “breaking the water” (artificial rupture of membranes (AROM)). Most mothers included in the survey were subject to 2 or more methods of induction, the most common combination being Pitocin and AROM.

Not only are many labors medically induced, but many are also augmented using the same methods listed above. When these numbers are included, about 50% of women are given artificial oxytocin to either induce or augment labor, and 65% have their water broken.

The risks…

More painful labor— Common induction methods such as artificial oxytocin can lead to longer and stronger contractions that are closer together. This means more pain for the mother during contractions, as well as a shorter period of time between contractions to recuperate. This can quickly exhaust a laboring woman, not to mention tarnish her birth experience. Many women whose labors are induced or augmented find an epidural to be a necessity.

“I went into labor on my own with my daughter, but was induced with my son. With my daughter, I found that sitting in a warm bath made the pain very manageable, and I didn’t get the epidural until very late — 7 cm, I think. With my son, I got an epidural at 3 cm — I just couldn’t stand the pain.” — Annie, 31

Prematurity — Miscalculation of due dates can lead to a woman being induced before her baby is mature. Iatrogenic (doctor-caused) prematurity is on the rise, and with it comes all the risks commonly associated with prematurity, such as breathing problems. New research shows that the production of fetal lung proteins trigger labor — meaning that the baby triggers spontaneous labor when its lungs are ready to breathe. Inducing without medical indication means your baby may not be totally ready to breath independently. Labor should NEVER be induced before 39 weeks for this reason, and should ideally be around 42 weeks as long as the baby shows no signs of distress.

Fetal Brain Damage or Death — The only time a fetus can get oxygen is during the rest period between contractions, so when those periods are shorter, the fetus gets less oxygen. Lack of oxygen is associated with an increased risk of brain damage.

Maternal death — According to Marsden Wagner’s book Creating Your Birth Plan, induction of labor is linked to higher rates of uterine rupture and amniotic fluid embolism (AFE), both of which are rare but usually fatal (80% of AFEs are fatal — 50% within the first hour after symptoms appear). C-Section dramatically increases the incidence of both. Many women who survive uterine rupture undergo hysterectomies and are unable to have any more children, and most that survive AFEs are severely brain damaged. Fetal death is also common with both of these complications.

“Cascade of Interventions” — A woman who is either induced or has her labor augmented artificially is at an increased risk of instrumental (forceps and vacuum-assisted) and surgical (c-section) interventions. So even if the induction drug itself is considered safe (which Pitocin is), the risks associated with all other forms of intervention must be calculated as well. While the more severe risks (uterine rupture, AFE, fetal brain damage) are relatively rare, the so-called “cascade of interventions” is fairly common. A woman who is induced more than doubles her riskof having a C-Section. A woman who goes in to be induced may find her plans for a low-intervention birth go awry very quickly.

“I got induced at 41 weeks because they thought she was going to be too big too birth otherwise. First came the Pitocin, then the epidural for the increased pain, which meant I was tethered to the bed with IVs, so I couldn’t move around. Then my labor slowed down, and they broke my water to speed things up. I went into labor thinking that I could manage an induction naturally, but instead I ended up with a C-Section because of failure to progress.”— Silvia, 26

Interferes with Bonding/Breastfeeding — Artificial oxytocin alters the mother’s natural hormones during and after birth, potentially affecting her ability to bond with or breastfeed her baby. Any other interventions she experiences (such as cesarean) can also interfere.

“When my son was born, I felt like he belonged to someone else. I kept waiting for that overwhelming feeling of attachment I knew I was supposed to feel, but it just didn’t come — I felt like I was just going through the motions for weeks.” — Patty, 29

What is the alternative?

So if induction carries with it the risks listed above, it could be argued that elective induction is not in the best interest of the mother or baby. So what’s the alternative? Well, waiting. Just remember, every day your baby “cooks,” s/he will be a little bit stronger, a little bit healthier. As we talked about last week, babies can and have been (vaginally) born past their due dates perfectly healthy. Trust your baby, and trust your body to go into labor on your own — it’s better for both of you!